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Submitted November, 2018
My oldest child is grown now with a career and a growing family, but he used to just be a kid, and like all children, he needed a bedtime routine. All too soon he lost interest in bedtime stories but we still needed a way to wind down together at bedtime. In those days a set of encyclopedias was still on the shelf and for a while we ended the day exploring the world together in those books. We would randomly select a volume, then flip it open read about whatever was on the page we landed on. It’s surprising how many of those random facts I still remember today. One evening we read about “true north.”
I always thought that a compass points to the North Pole. Like so many other things, I was wrong. True north is the direction along the earth's surface towards the geographic North Pole. It is almost identical to astronomical true north, calculated for centuries by ocean bound navigators. It is a static, predictable point mariners have depended on since man began to travel.
Magnetic north is a wandering point in the northern hemisphere where the planet's magnetic field is vertically centered. It is the direction compasses point. Magnetic north varies slightly from year to year, altered by natural and man-made magnetic fields. Following magnetic north as a navigation strategy over long distances to precise points will inevitably cause us to become lost, as ancient mariners knew.
And so all these years later, this fun fact I learned with my son one evening returns to haunt me (and now you) as a metaphor. In life's journey we are often uncertain where we stand, where we are going and what is the right path. True North is the internal compass that guides you successfully through life. It represents who you are as a human being at your deepest level. It is your point of orientation - your fixed point in a spinning world - that helps you stay on track as a leader and as a human being. Your True North is based on what is most important to you, your most cherished values and beliefs, your passions and motivations, the sources of satisfaction in your life. Ignoring or leaving True North unexamined is dangerous and can rob life of meaning. Finding and following True North is the difficult work that defines our lives.
When it comes to vocation, we might consider True North as another way of describing our calling—how we match what is deep within our heart and the unique gifts we have been given, with what the world cries out for in need.
I speak to physician groups frequently about burnout and wellness, and many times I have flipped through my well-worn power point slides about both. More and more it occurs to me now that most of these slides are ultimately useless unless we as individuals spend more time exploring, discovering and then tenaciously following our own unique True North.
Most of us were in small practices when my career began, now 70% of physicians are employed. Often, our professional lives are influenced, if not controlled, by people far removed from the realities and sacredness of the exam room. To practice in an environment that ignores the importance of things like calling, relationships, values, respect and meaning, instead focusing most visibly on profit and market share, devalues the humanity in our work and its wake can land us as individuals onto a rocky shoreline before we even realize we have strayed off course. Self-examination in medicine these days requires not only examining what is deep within us, but also what we allow to go on around us. If our own values and calling are in conflict with the practice or organization we work within, we go to work each day in great personal peril. Fortunately, we have some great leaders in our medical community, many of whom support the Physician Wellness Program, who are increasingly committed to physician wellbeing. Be a voice within your organization. Watch out for your colleagues. We still have a long way to go.
Submitted September, 2018
The Cloud of Witnesses
During my years in study at an Episcopal seminary, I came to appreciate the reverence Episcopalians have for the saints. There are hundreds of recognized saints and one semester I spent several months studying some of their life stories and the spiritual gifts they left behind. The Old Testament refers to the "cloud of witnesses," the faithful who pave the way for subsequent generations. Of course, the importance of the heritage of important figures in inspiring and giving us direction is not unique to religion. As Americans, we venerate the founding fathers, Lincoln, King, and many others. There are legendary athletes that sports fans compare modern day athletes to, as well as educators, authors, scientists, social activists. Imperfect as they were, their life stories are guideposts of inspiration. Medicine is no exception. Lister, Curie, Freud, Fleming, Jenner, Osler, DeBakey, and so many other giants along with the teachers and mentors who paved the way for us. The cloud of witnesses is sometimes likened to the crowd that cheers you on as you run a marathon or 10k. Often nameless and faceless, but full of those who care about us, want success for us, cheering us on.
For the last few years, I have had the honor to write memorials in the TCMS Journal for our departed colleagues. Some were well known to me, others I never met. Given the generation now passing, most are male, almost all served in the military, the majority trained in Texas or the south. The women of that generation who have passed serve to create a very special witness to our profession, their unique obstacles as women in medicine in that era an especially rich heritage. As I piece together their lives, not surprisingly what stands out more than the accomplishments that punctuated their lives is the heritage of compassion, accessibility, friendship, and faithfulness they imbedded in the hearts of the lives they touched. Poet David Whyte notes, "Death is not impressed by what we have done, unless what we have done leaves a legacy of life...what is remembered in all our work is what is still alive in the hearts and minds of others.” I often think of doctors who I have worked with, along with mentors and teachers who are gone now but gave me gifts that I still call on today. They likely had no idea that I would see things in them that I would carry with me that make me a better doctor and a better man.
We accomplish much in our lives as doctors. We make lives better, cure or control disease, and, on a good day, even connect with patients and bring real healing, often against great odds. We should not lose sight of the fact that connecting with colleagues, being available to listen and advise, to be an encouraging and compassionate presence, is one of our primary callings and ultimately is the most important thing we leave behind to our colleagues and our profession.
These are difficult times to practice medicine. We know that burnout is all around us – statistically about half of us – and not just the usual irritations of work but true burnout with life altering effects that shade all phases of our lives as well as impacting patient safety. Keep an eye out for colleagues who may be struggling, check in with them, encourage them to get help or at least talk about it. Realize it or not, your life is an example to those around you and there are unseen opportunities to help your colleagues who may need help but don’t get it out of shame or denial.
Submitted July, 2018
The Hero’s Journey
Since childhood, one of my favorite stories is David and Goliath, the story of the young, future king who finds himself – by a combination of chance and choice – facing the Philistine giant. The fate of his army depends on him alone, with only his wits, faith and courage to perform a seemingly impossible feat. We might all identify with this story, as we have all felt ourselves to be an underdog at some point in our lives. As I was preparing a class about this story recently, I came across an essay about the “monomyth” or “The Hero’s Journey.” Described by author Joseph Campbell and others, the Hero’s Journey is a basic story pattern throughout mythology, a pattern frequently found in other ancient writings as well as later day literature and film.
A very brief summary of the stages of The Hero’s Journey is as follows: the hero from the ordinary world is called to adventure. After initially refusing the call, he crosses the threshold into a supernatural region. He descends into “the belly of the whale” and “the road of trials,” along the way meeting with helpers, mentors, a goddess, a temptress, and seemingly insurmountable challenges. There is atonement with a higher power, then receipt of the boon (treasure) and apotheosis (achievement of a higher level of existence), finally rebirth and return to the ordinary world, now possessing gifts to bestow on humanity.
Literature is often a reflection of everyday life, and if we spend a little time thinking about it we may be able to see many small, and perhaps a few large, monomyths in our own lives. Our lives in medicine these days is easily seen through this lens. We pass through a certain threshold from our early lives into a life of medicine, lives that are full of mentors, challenges, temptations and perhaps dark times spent in the “belly of the whale.” But like the heroes in many of the stories, as we navigate difficult times the treasure that we acquire may be a certain kind of knowledge, perhaps even wisdom, a boon that we are called to share with our colleagues and all of humanity, one patient at a time. To achieve and then share the gifts that we attain on this journey is indeed heroic, anything but ordinary, but often obtained at great cost.
Different authors describe The Hero’s Journey in different terms, but all include the importance of the “mentor” or “supernatural aid” that assists in the journey. We may find this assistance in several ways. One is deep within our own souls, beyond ego where our deepest desires and meaning lives, a place it takes some effort to reach. Another is found within our community of colleagues, bound together with common hopes and goals, supporting each other, sometimes going arm and arm down the “road of trials,” then hopefully beyond it. Lastly, there is something woven within, but also beyond, both of those. On my desk I have a fortune from a fortune cookie with a well-known saying: “Act boldly and unseen forces will come to your aid.” The ambiguous sounding “unseen forces” is open to individual interpretation. In my own life it means something very specific, but beyond that, the saying is significant in calling on us to whine and retreat as little as possible in the face of life’s important challenges, but rather to act boldly as we carry our gifts and dreams into a world in need, regardless of obstacles in our way, and to do so in a way that breathes life into us and those around us.
Submitted April 30
An Endangered Species, or an Evolving Species?
In an article from the last issue of the TCMS Journal, Dell Medical School Dean Clay Johnston, MD, PhD, makes insightful observations about the future of practicing physicians and the mindset we will need to remain relevant. Are physicians, at least as we have traditionally considered ourselves, really an endangered species? He observes what many of us have already grudgingly concluded: that the capabilities of AI (artificial intelligence) will increasingly replace much of the data storage and problem solving tasks that physicians have traditionally seen as their own unique gifts. As this happens rapidly and predictably, what will be the role of physicians? Will that new role be an entirely new direction for us, or a return to the deepest roots of the healing profession?
Dr. Johnston notes that the way medical schools train physicians will need to undergo a sea-change to prepare the next generation of physicians: “Most allocate substantial time to memorization and analysis, tasks that will become less demanding as artificial intelligence improves. But components of the art of caring—communication, empathy, shared decision-making, leadership, and team-building—are underemphasized, when they are emphasized at all… It’s essential that medical education leaders rebalance their curricula toward these components. Doing so will help patients receive the best care that medicine and machine have to offer. It may be good for physicians as well, as they find more opportunities for meaningful patient communication and delivery of higher-quality care.”
Dr. Johnston notes, “We know that the art of caring is central to the medical profession.” Indeed, it is one of the few things that AI cannot replace. Physicians will need to remember that curing and healing are not the same and our call as physicians in providing care is to endeavor to restore wholeness to the person, not just the body.
How do we realign this mindset as a profession? Daniel Sulsmasy, in his article, Is Medicine a Spiritual Practice?, observes that for physicians to really connect with their patients they must be willing to explore, or at the very least acknowledge, that patients struggle with “the big questions. What is the meaning of my illness? Why must I suffer? Is there anything about me that is valuable now that I am no longer ‘productive?’... Can my doctor possibly understand what I am really going through? A physician who has begun to explore these questions in his or her own life will be better prepared to help patients struggle with these questions.”
Submitted March 28
The Medical Marriage
Adam Taylor/ABC via Getty Images
First the good news. Contradicting earlier studies with potentially flawed designs, a study out of Harvard that looked at data from 6 million people, including 40,000 physicians, found that physicians, 27% of whom reported ever being divorced, are actually less likely to divorce than the general population of non-healthcare employed people, 35% of whom had been divorced. Broken down into healthcare professionals, we stack up well again, less likely to have experienced divorce than dentists, healthcare executives and nurses.
In spite of this good news, married physicians face unique challenges to be navigated. Our work as physicians can be highly stressful and involve long hours physically (or emotionally) away from our families. We often bring these stresses home with us. The traits that can make us excel as physicians as often as not may make us a challenge to be married to. Women in medicine often face an additional set of challenges balancing work and family life and are 1.5 times more likely to have been divorced than their male counterpart of similar age, with women physicians working more than 40 hours per week at particular risk.
So what is the key to a successful medical marriage? A number of strategies have been suggested. One study from Mayo Clinic looking at factors that work for and against the medical marriage from the spouses vantage point demonstrated that “on multivariate analysis, minutes spent awake with their physician partners each day was the strongest predictor of relationship satisfaction, exhibiting a dose-response effect.” Other studies have also identified time together as the key, although at least one has demonstrated that quality time is really the key with spurts of just 30-120 seconds of “caring interaction for a total of 20-30 minutes a day,” to be a key predictor of marital success (Sotile/Fraenkel). By any measure, time with your spouse is a critical ingredient, also one very difficult to navigate when so much time and emotional energy are consumed by career and the “parenting vortex.”
In April, the TCMS Physician Wellness Program is proud to add a Certified Gottman Couples Therapist to our coaching panel for couples in need of expert help in making their marriage the best it can be. Here is more information about couples coaching as well as our coaching program.
Submitted March 5
When 20% is a Passing Grade, but Surprisingly Hard to Get
Last fall I attended a nationwide conference on physician burnout and resiliency in which a researcher from Mayo Clinic presented data about causes of physician burnout. In the study, they looked at certain characteristics of physicians who fulfilled criteria for burnout and those who did not and tried see how the two groups differed in certain categories
They asked participants to identify what work related activities they find most meaningful. Examples included direct patient care, administration, research and education activities. They found that physicians who spend at least 20% of their time on their most personally meaningful activity have a burnout rate that is half of those who spend less than 20% of their time on favored activities. It is, of course, both amazing and frightening to think how many physician fall short of that low percentage in their workday, but not surprising what the consequences are.
Shortly before I sat down to write this, I listened to a podcast during a run that featured Shawn Achor, an expert in positive psychology. In describing the “secrets of happiness” he notes the importance of redefining how we think of happiness. His argument is that if we define happiness only in terms of pleasure or the final accomplishment of a goal, then happiness is never more than a fleeting moment in time. He calls on us to see happiness as primarily being “the joy we feel while striving towards our potential.” The potential he refers to is our ultimate capacity for optimizing relationships, vocation, and other integral aspects of our lives. Intimately linked to realizing joy and happiness, he argues, is a sense that the things you are involved in have meaning.
As we try to navigate our professional careers towards happiness and fulfillment, an important call is to recognize what part of our work is most meaningful to us and to make sure that in the course of a normal workday that activity is consistently and proportionately represented.
What specific activity is most meaningful to you? How well is it represented in a typical day?
Submitted Febuary 2
Healing From Within
I have been an internal medicine physician for over two decades
and have traveled the world both as a missionary physician and a tourist. When
I am home in the United States, I can feel a palpable and growing level of
stress in our communities across America, as evidenced by the ever-increasing
opioid crisis, alarming rates of obesity, rising statistics of violence,
depression, and sadly, suicide. This level of stress is much higher in the
United States than other countries I visited. I have felt helpless for many
years, not really knowing how to treat my patients facing stress-induced diseases.
How could I? Like many of my colleagues, I was practicing with burnout symptoms
for many years.
Then, in 2009, I had a personal tragedy so horrific that I knew
prescription medicine could not help me to heal. I had to find a different way.
I was encouraged to try meditation. Despite my skepticism, I decided to put
effort into the daily practice of meditation. To my surprise, it worked. It not
only took away the emotional pain and burn-out symptoms but replaced it with a
deep joy that is difficult to describe.
This led me into research for the next several years on why and
how meditation heals. What I found was substantial research in meditation in
major universities throughout the United States, particularly at the University
of Massachusetts and Harvard Medical School. Meditation is offered as treatment
for many conditions including hypertension, depression, anxiety, ADD/ADHD, just
to name a few. Meditation reduces complications to chemotherapy, radiation
therapy, AIDS treatment, surgeries, and the list goes on and on. Meditation
works because it counteracts the stress response creating a relaxation response
that allows the body to heal. It is now considered a significant evidence-based
practice in medicine.
Meditation is currently widely used in many occupations. It is
being adopted in the military for stress and resiliency. In the corporate
world, companies such as Google, have incorporated meditation into the work day
as it has shown to improve morale, focus, less sick days, and increased
productivity. Schools are using meditation instead of detention, showing
improved attention, behavior, and grades. Even in sports, professional football
players and Olympians use meditation daily to help their focus.
I practice a meditation called the Centering Method, a
mindfulness meditation. It is a simple method that elicits the relaxation
response when practiced daily. I brought this meditation practice to physicians
in 2014. We now have ongoing workshops at setoncove.net.
Meditation has been practiced for thousands of years. However,
we have only started to study its benefits. I see a future where we learn that
the power of healing is truly within each of us.
Anna Vu-Wallace, MDDr. Vu-Wallace is a hospitalist and is
founder of the Mindfulness Meditation Clinic at Seton Cove
Submitted December 31
beginning of each new year often becomes a sort of artificial but important
threshold, a time when we look back on the old, both regrets and joys, and wonder
about the year to come. Some years when happiness and abundance have marked our
year the transition is easy, almost entirely unexamined, while other years,
recent events of loss or regret challenge us toward self-examination and
change. To acknowledge and navigate significant change, a threshold, in any
meaningful way requires honest reflection and courage. The late poet John
O’Donohue commented on such times of challenge:
acknowledge and cross a new threshold is always a challenge. It demands courage
and also a sense of trust in whatever is emerging. This becomes essential when
a threshold opens suddenly in front of you, one for which you had no
preparation. This could be illness, suffering or loss. Because we are so
engaged with the world, we usually forget how fragile life can be and how
vulnerable we always are. It takes only a couple of seconds for a life to
change irreversibly. Suddenly you stand on completely strange ground and a new
course of life has to be embraced. Especially at such times we desperately need
blessing and protection. You look back at the life you have lived up to a few
hours before, and it suddenly seems so far away. Think for a moment how, across
the world, someone’s life has just changed – irrevocably, permanently, and not
necessarily for the better – and everything that was once so steady, so
reliable, must now find a new way of unfolding.”
thresholds are abrupt and dramatic as O’Donohue describes. More often, arrival
at one of life’s thresholds is more subtle, but no less profound and
challenging to discern and cross. In such times, we need to call on not only
the invisible strength found within us, but also the support available from
those around us, to produce visible and productive change. As he goes on to note
in his poem “For the Interim Time,”
during such times,“What is being transfigured
here is your mindAnd it is difficult and slow
to become new.The more faithfully you can
endure here,The more refined your heart
will becomeFor your arrival in the new
We hope the old year
ended with happy memories, gratitude, and professional satisfaction and that
the New Year will be full of family and friends as well a sense of purpose and
meaning in your work. If you find yourself in a time of challenge and in need
of help, please consider reaching out to the PWP confidential coaching program,
where one of our professional counselors is only a phone call away.
Submitted November 29
It’s the Most Wonderful Time of the Year (?)
In the midst of digging out of the colossal mess left over from our great family gathering at Thanksgiving, then bringing down the seemingly endless boxes of Christmas decorations from the attic to sort through, I convinced myself it might be therapeutic to read about survival/enjoyment during the holidays. Here’s a few of the most common tips:
Can this be the most wonderful time of the year? Absolutely! It should be full of family, friends, fun, rest and meaning. It just takes the right mindset and maybe the ability to pause and take a deep breath every now and then.
If are struggling and think you might need a little help, consider calling the 24-hour confidential PWP coaching hotline 512-467-5165 and we will help you connect with one of our TCMS counselors by phone or in person.
On Being Perfect
Compulsive, perfectionist. Personality traits often blamed as root causes of physician burnout. There is a part of perfection seeking that makes us better doctors, but another part that can be profoundly destructive. When we fall short of our own expectations, either through our own missteps or because of things we cannot control, with the wrong mindset it can send us into a spiral of self-doubt, hesitation or defensiveness that impairs our ability to provide good care for patients, and ourselves.
No matter how hard we try, sometimes things go wrong. It is part of our lives in medicine, life in general for that matter, which goes against our quest for perfection, a quest we take on in equal measure for our patients and our egos. At some point we have to come to terms with imperfection, with failure, and see these events for what they are and what they teach us and at some point redefine what perfection really means.
I am a sucker for old sports movies as they study not only those who succeed, but also those who seemingly fail. My favorite scene in Friday Night Lights is the halftime pep talk that the coach, played by Billy Bob Thornton, gives during their championship game:
“…You got two more quarters and that's it. Now, ya'll have known me for a while, and for a long time now you've been hearin' me talk about being perfect…To me, being perfect is not about that scoreboard out there. It's not about winning. It's about you and your relationship to yourself and your family and your friends. Being perfect is about being able to look your friends in the eye and know that you didn't let them down, because you told them the truth. And that truth is that you did everything that you could. There wasn't one more thing that you could've done… Can you live in that moment, as best you can, with clear eyes and love in your heart? If you can do that gentlemen, then you're perfect.”
As physicians, perhaps we should learn a lesson from the coach, redefine perfection and know you can achieve it, regardless of the outcome, when you can look into the eyes of your patient, and into the mirror, and can truthfully say you did everything you could, there wasn’t one more thing you could have done, and say it with clear eyes and love in your heart.
Submitted October 6
I was the senior resident in the ICU. It was late and I was
exhausted. A sleet storm was in progress outside the hospital and miles away in
a remote area in far northern New Mexico a blizzard was in progress. Somehow Life
Flight had managed to get out ahead of the storm and transported Roy to County where
he landed on my service. He arrived in cardiogenic shock with ominous tall,
wide ST elevations that we identified as “tombstones,” signifying what in those
days would as likely as not be a fatal event.
The usual frenzied dance followed, using protocols that sound
primitive now, all the while knowing his chances were slim. He rallied after I had
sent the interns and students off to get a little sleep, was even oriented and
conversant for a while before the arrest and futile code. He told me about his
ranch, snow covered now, but soon, in the spring, lush green pastures would
re-emerge in a valley below two tall mountains, snow fed streams coursing through
the valley. A family ranch where his wife was now stranded in the storm, and
where tomorrow his son would have to try and drive the pickup into the pasture,
his grandson pushing square bales out into the snow for the cattle as they went
along. The old man’s face was pale, deeply creased, sun damaged, and now with
tears. I think that night was the first time I held a patient’s hand for more
than an instant, in this case for an hour or more, his hand clutching mine at
times. By 7:00 a.m. my shift was done, and so was Roy. I called his wife then
headed home, and slept.
We have talked about physician wellness a lot lately and it
occurs to me that at the core of it lies compassion, of sharing the suffering
of others. Burnout and compassion travel against each other with opposite trajectories,
one always ahead of the other. Our lives in medicine are defined by compassion,
both in giving it, but also in feeling worthy of receiving it. We might ask
ourselves many times in a long career, “How do we nurture and protect it?” Without
compassion, we are just technicians.
Even today I will sometimes see a cardiac monitor in the
unit and think of Roy. Most years, driving to a favorite spot in Colorado I
will pass by a certain wide pasture, emerald green, framed with tall mountains,
dotted with cattle, and pray that I will never forget that night.
Submitted September 5, 2017
The Inner Environment
For physicians who go through a period of dissatisfaction (or worse) with their work, there is a tendency to blame external factors. This is encouraged by countless articles and books written about physician burnout in recent years. It is hard to ignore the factors that seem to conspire against us. The systems we work in that sometimes appear to be as concerned with production as with quality, the avalanche of regulatory requirements, and the disproportionate amount of time we spend with EMRs and wrestling with insurers. All of these things, and many others, take us away from the one thing that physicians value most in reflective moments – unpressured time to have meaningful, human interaction with their patients. True as this might be, at some point we may have to realize that while there are “systems” problems in our work that we cannot control, what we can control is how we react to these potentially destructive forces, and in doing so, we just might preserve a sense of joy and meaning in our work. Controlling how we respond takes hard work, perhaps the hardest kind. It requires that we look inward.
Ronald Epstein, author of Attending: Medicine, Mindfulness and Humanity, and our 2017 TCMS Foundation Lecturer, speaks of this in his book: “Burned-out physicians are not only alienated from patients; they are also alienated from themselves…. But changing the health care system won’t solve it all. It is important to recognize that burnout has affected clinicians for centuries, and important causes of burnout reside within clinicians themselves. For the first time in memory…some doctors are finally paying attention to their inner environment in a systematic way and finding ways to bring greater presence and resilience to the practice of medicine.”
Paying attention to what Dr. Epstein describes as the “inner environment” is a unique process, requiring skills, patience and self-examination that does not come naturally to most of us, but the rewards for us and our patients can be immense. It is work that leads to the meaning and connection in our daily lives that we always assumed awaited us when we put on that first white coat.
-A PWP committee member
Submitted: July 20, 2017
During the past year I have been a part of a couple of physician wellness workshops in which one of the speakers uses an exercise about our calling to be physicians as an ice breaker.
She asks members of the audience to turn to one or two people sitting next to them, preferably someone they do not know well, and tell the story of how you decided to become a doctor. It is a little awkward telling someone you don’t know something about you that is potentially either a fairly
personal story, or one that might just sound lame, or a story you can’t fully put into words. Over the years, patients have asked me often enough why I wanted to be a doctor and I reply with something very brief and unrevealing−more of a sound bite than a real explanation. But with a colleague, and
in this type of setting, I have found that it does make me think more carefully, to recall complex feeling and events that led to the decision, and then share it with a relative stranger.
It does create an instant bond of sorts, perhaps even a new friend, something that is clearly part of the exercise.
There is also great power recalling and verbalizing the nature of that call all these years later.
The second part of the exercise is then to address the question, “Why do you continue to practice medicine today?” If the second answer is different from the first, and it often is, that is certainly food for thought. Is the sense of calling to medicine at our current stage of life one that energizes us,
fills our work with meaning, our lives with joy even in the face of challenge, or is it now a life of perceived drudgery and annoying obstacles? The answer may say much about how we interact with patients and loved ones, and whether strategies for change/renewal are needed.
Considering the need for a course correction might start with a challenge described by author David Whyte: “…try to imagine what that dreaming young self would think of the strange adult we have become.”
-A late career internist